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Community health workers and the midwifery workforce - 23_nov2014 - Giorgio Cometto
1. AMREF Health Africa International Conference
Nairobi
25 November 2014
Dr Giorgio Cometto,
Global Health Workforce Alliance
World Health Organization
Community health workers and
midwifery workforce: reflections
on evidence and future agenda
2. 2 |
Human resources for health:
global challenges, global opportunities
Source: Campbell et al, GHWA and WHO, 2013
3. 3 |
Community health workers: an opportunity
for maternal and child health, HIV, TB …
"Lay health workers provide promising benefits in promoting immunisation
uptake and breastfeeding, improving TB treatment outcomes, and reducing
child morbidity and mortality when compared to usual care" Lewin et al, Cochrane Rev,
2010
"Community health workers …were found to be especially effective in
promoting mother-performed strategies (skin to skin care and exclusive
breastfeeding)." Gilmore and McAuliffe, BMC Public Health 2013
"Community health workers were reported to enhance the reach, uptake and
quality of HIV services, as well as the dignity, quality of life and retention in
care of people living with HIV. The presence of CHWs in clinics was reported
to reduce waiting times, streamline patient flow and reduce the workload
of health workers. Clinical outcomes appeared not to be compromised." Mwai et
al J Int AIDS Soc 2013
4. 4 |
… and more
"Non-specialist health workers have some promising benefits in improving
people's outcomes for general and perinatal depression, post-traumatic
stress disorder and alcohol-use disorders, and patient- and carer-outcomes
for dementia" van Ginneken et al, Cochrane Rev, 2013
"Overall, the studies consistently identified positive outcomes associated with
CHW-delivered interventions, including decreased asthma symptoms,
daytime activity limitations, and emergency and urgent care use." Postma et al J
Asthma 2013
"CHW programmes can have large impacts on the control of Buruli ulcer in
sub-Saharan Africa." Vouking et al, Pan Afr Med J 2013
5. 5 |
Midwifery scale-up could avert 83% of all
maternal and neonatal deaths, stillbirths
Source: Homer C, Friberg I et al, Lancet, 2014
6. 6 |
Success in reducing maternal mortality hinges
on facility births and midwifery scale-up
Source: Van Lerberghe W, Matthews Z et al, Lancet, 2014
7. 7 |
Midwifery-led services can have better
outcomes than standard care models
Source: Lassi Z, Cometto G et al, WHO Bulletin, 2013
Lower use of intra-partum regional anaesthesia and episiotomies in
midwifery-led care compared to traditional physician-led care
8. 8 |
Value for money of CHWs investments
"Using country GDP per capita as the WHO reference threshold for cost-
effectiveness, all three CHW programmes found to be cost-effective.
Incremental cost per life year gained was estimated to vary between $82 and
$3,396. ... the CHW-led approach has a high likelihood to be a cost-effective
approach to delivery of some essential health interventions." McPake B, Edoka I et
al, GHWA and WHO, 2014 (Health Systems Research Symposium abstract; forthcoming publication)
9. 9 |
Value for money of midwifery investment
16-fold Return on
investment in terms of
lives saved and costs of
Caesarean sections
avoided
through investments in
midwifery education and
deployment to community-
based services.
(State of the World’s Midwifery, 2014)
10. 10 |
The next frontier: CHWs in health systems
• Community
preparedness
• Regular and sustainable
remuneration package
• Opportunities for
professional
development
• Ensure supplies/
equipment
• Effective referral
systems
• Regular monitoring &
supervision
• Clear/ transparent
selection system
involving communities
• Curriculum to include
scientific knowledge
on basic preventive
and curative care
• Adapt contents to
health system needs
• Include CHWs in HRH
planning
• Have a budget line /
resource allocation
Planning
Production/
Education
Deployment
/ retention
Perfor-
mance
Source: Bhutta et al, GHWA, 2010
11. 11 |
The next frontier (2)!
Effective coverage of midwifery care
workforce is
AVAILABLE?
workforce is
ACCESSIBLE?
workforce is
ACCEPTABLE?
workforce
provides QUALITY CARE?
AVAILABILITY ACCESIBILITY ACCEPTABILITY QUALITY
• A midwife is available
in or close to the
community
• As part of an integrated
team of professionals,
lay workers and
community health
services
• Woman attends
• A midwife is available
• As and where needed
• Financial protection
ensures no barriers to
access
• Woman attends
• A midwife is available
• As and where needed
• Providing respectful
care
• Woman attends
• A midwife is available
• As and where needed
• Providing respectful care
• Competent and
enabled to provide
quality care.
CRUDE COVERAGE EFFECTIVE
COVERAGE
Source: SoWMy 2014
14. 14 |
Remember the future!
Consider long-term vision for CHW integration
• CHWs often seen as short-term stop-gap measure
• But increasing and evolving needs on the horizon, i.e. "0"
targets, growing NCD burden, demand for quality
• Fiscal space improvements will allow greater investment in skilled
HRH
• Role of CHWs to evolve over next decades: less diagnostic/
curative, more health promotion, chronic care management,
treatment compliance
• Plan for CHWs with the country's long-term needs and vision in
mind
• Envisage evolving role for CHWs in health systems
• Tailor selection, education, career pathways accordingly
15. 15 |
Remember the future (2)!
Enable midwifery scale-up and practice
Enabling policy
environment
Enabling
practice
environment
-align job titles, roles and responsibilities
-allow to practice within full scope of
profession
-strong linkages education/ employment
-licensing/ re-licensing systems
-improve salaries
-incentive for rural deployment/ retention
-access to effective referral
-professional development opportunities
16. 16 |
Further information
Health Workforce Department, WHO &
Global Health Workforce Alliance
World Health Organization
Avenue Appia 20 CH-1211 Geneva 27 Switzerland
Email: ghwa@who.int
http://www.who.int/workforcealliance/en/
http://unfpa.org/public/home/pid/16021
http://www.thelancet.com/series/midwifery
Notas do Editor
Efforts to achieve the health targets of the UN Millennium Development Goals set in 2000 are thwarted in many countries by shortages of health staff, their often inequitable distribution, and gaps in their capacity, motivation and gaps in their capacity, motivation and performance.
The ambitious targets under consideration for by the United Nations as part of the Sustainable Development Goals that will replace the MDGs will only be achieved if dramatic improvements are made to strengthen the health workforce.
Low- and middle- income countries face the most severe challenges when in ensuring a sufficient, fit-for-purpose and fit-to-practice health workforce.
But countries at all levels of socio-economic development face the challenge of how to sustain the human capital required to guarantee universal access and universal health coverage. High-income countries in particular are often over-reliant on migrant health workers from developing countries, and have to plan for the growing need of the population.
We used the Lives Saved Tool (LiST) to estimate deaths averted if midwifery was scaled up in 78 countries classifi ed
into three tertiles using the Human Development Index (HDI). We selected interventions in LiST to encompass the
scope of midwifery practice, including prepregnancy, antenatal, labour, birth, and post-partum care, and family
planning. Modest (10%), substantial (25%), or universal (95%) scale-up scenarios from present baseline levels were
all found to reduce maternal deaths, stillbirths, and neonatal deaths by 2025 in all countries tested. With universal
coverage of midwifery interventions for maternal and newborn health, excluding family planning, for the countries
with the lowest HDI, 61% of all maternal, fetal, and neonatal deaths could be prevented. Family planning alone could
prevent 57% of all deaths because of reduced fertility and fewer pregnancies. Midwifery with both family planning
and interventions for maternal and newborn health could avert a total of 83% of all maternal deaths, stillbirths, and
neonatal deaths. The inclusion of specialist care in the scenarios resulted in an increased number of deaths being
prevented, meaning that midwifery care has the greatest eff ect when provided within a functional health system with
eff ective referral and transfer mechanisms to specialist care.
This paper complements the other papers in the Lancet Series on midwifery by documenting the experience of lowincome
and middle-income countries that deployed midwives as one of the core constituents of their strategy to improve
maternal and newborn health. It examines the constellation of various diverse health-system strengthening interventions
deployed by Burkina Faso, Cambodia, Indonesia, and Morocco, among which the scaling up of the pre-service education
of midwives was only one element. Eff orts in health system strengthening in these countries have been characterised by:
expansion of the network of health facilities with increased uptake of facility birthing, scaling up of the production of
midwives, reduction of fi nancial barriers, and late attention for improving the quality of care. Overmedicalisation and
respectful woman-centred care have received little or no attention.